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Transcatheter closure of post myocardial infarction, iatrogenic, and congenital ventricular septal defects

Introduction Transcatheter closure of ventricular septal defects (VSDs) is a less invasive treatment option for patients with suitable anatomy for device closure and those who are considered to be high-risk candidates for surgical therapy. , This chapter provides an overview, procedural techniques, and outcomes of transcatheter VSD closure. AHA guidelines Device closure of a muscular VSD may be considered, especially if the VSD is remote from…

Atrial septal defect, patent foramen ovale, and atrial septostomy

Atrial septal defect Indications Device closure of an atrial septal defect (ASD) is indicated for patients with secundum defects less than 38 mm in diameter, who have evidence of right ventricular volume overload, and do not have associated cardiac abnormalities that would otherwise be better suited to a surgical approach ( Fig. 19.1 ). Coexistent conditions that might prompt consideration of surgical repair include severe atrioventricular…

Mitral valve-in-MAC

Introduction Patients with symptomatic severe mitral valve disease due to severe mitral annular calcification (MAC) are often elderly with multiple comorbidities and have a high risk of cardiovascular death. Their surgical risk for standard mitral valve surgery is high due to comorbidities and technical challenges secondary to severe calcification. Many patients are not offered standard mitral valve replacement due to their high surgical risk. Transcatheter mitral…

Mitral paravalvular leak closure

Introduction Paravalvular prosthetic leak (PVL) occurs in 6% to 15% of surgical prosthetic valves or annuloplasty rings secondary to degeneration and loss of integrity of the annular tissue. Moderate-to-severe PVL is associated with increased morbidity and mortality if left untreated. , PVL is more common with mitral prostheses and use of continuous sutures or sutures without pledgets. , Patients with chronic mitral PVL usually present with…

Percutaneous mitral valve-in-valve and valve-in-ring

Introduction Mitral valve disease is the most common cardiac valve condition, with the prevalence of significant regurgitation or stenosis increasing with age and estimated to be 9.5% in the general population above the age of 75. The most common treatments for severe mitral valve disease include surgical mitral valve repair (usually including an annuloplasty ring) or replacement with either a tissue or mechanical prosthesis. Patients receiving…

Percutaneous edge-to-edge mitral valve repair using the mitraclip®

Introduction Mitral regurgitation (MR) is the most common valvular regurgitant abnormality, increasing in prevalence with age and affecting approximately 4 million people in the United States alone. , Severe MR eventually leads to left ventricular (LV) dilation and dysfunction resulting in heart failure. Although surgical mitral valve (MV) repair or replacement remains the first-line treatment for MR, a significant fraction of patients are poor surgical candidates…

Percutaneous balloon mitral valvuloplasty

Introduction Mitral stenosis (MS) is the most common sequelae of rheumatic heart disease and is characterized by diffuse fibrous thickening of the margins of the mitral valve (MV) leaflets and fusion of the commissures. Untreated, severe MS can lead to significant derangement of the functional status of patients and reduced long-term survival. Since its introduction in the 1980s, percutaneous balloon mitral valvuloplasty (PBMV) has proven to…

Aortic paravalvular leak closure

Paravalvular leak (PVL) occurs in 5% to 17% of patients after valve replacement surgery. Although the majority of PVLs are subclinical, some patients develop symptoms of heart failure, hemolysis, or both, requiring intervention. Surgical repair or valve re-replacement is the historical gold standard for the management of symptomatic PVL, but is associated with significant morbidity and mortality, even in modern practice. Percutaneous PVL closure has proven…

Aortic valve-in-valve TAVR

Transcatheter aortic valve-in-valve (VIV) is an established treatment of degenerative surgical bioprostheses in patients at high operative risk and was approved by the US Food and Drug Administration in 2015. The aortic VIV procedure is not currently approved to treat para-prosthetic valve regurgitation or failed/degenerated transcatheter heart valves (THVs), and it is contraindicated in patients with infective endocarditis. Indications Although there are no randomized clinical trials…

TAVR alternate access sites

Background The transfemoral approach remains the first-line access choice for transcatheter aortic valve replacement (TAVR). Initially up to a third of patients were unsuitable for the transfemoral approach, although this has decreased to less than 10% with contemporary valve designs. In our experience, of 1337 cases (TF 1220, alternative access 117), we used alternative access in just 9% of cases. Common contraindications to the transfemoral approach…

Transfemoral TAVR complications

Complications Operators have to be prepared for all emergencies when performing transcatheter aortic valve replacement (TAVR). Complications should be managed by the team with predefined and discussed protocols, and these will be determined by local expertise. Bailout equipment should be readily accessible. Common complications during and after TAVR and how to address them are listed here: Unexplained hypotension —Look for etiology, start fluids, and add vasoactive…

Transcatheter aortic valve replacement using self-expanding valve

Self-expanding transcatheter aortic valve replacement: The medtronic corevalve system Currently in the United States, the most widely used self-expanding transcatheter aortic valve is the Medtronic CoreValve system. This transcatheter valve is made of a self-expanding nitinol frame with leaflets composed of porcine pericardium. The Medtronic CoreValve system has undergone two design iterations to improve the outcomes after implantation based on trial and registry data. The first-generation…

Balloon expandable transcatheter aortic valve replacement

Introduction The only balloon-expandable valve currently on the market is the Edward Sapien Heart valve manufactured by Edwards Life Sciences. This chapter will focus on the procedural techniques involved in the use of this balloon-expandable prosthesis. Edwards sapien balloon-expandable heart valve prosthesis The Edwards Sapien heart valve system is made up of a cobalt–chromium frame with three bovine pericardial leaflets. The frame has open upper and…

Transcatheter aortic valve implantation: Work up and indications for intervention

Background Aortic stenosis is the most common valvular heart disease in the elderly population, with a prevalence of approximately 3% in patients over 75 years old. The prognosis of symptomatic severe aortic stenosis is poor, with a 50% mortality rate at 2 years; therefore valve replacement is usually recommended once symptoms of shortness of breath, heart failure, or angina occur. In the majority of patients, the…

Balloon aortic valvuloplasty

Background Aortic stenosis (AS) is common in the elderly population, with a prevalence of approximately 3% in patients over 75 years old. The prognosis of symptomatic severe AS is poor, with a 50% mortality rate at 2 years; therefore valve replacement is usually recommended once symptoms of shortness of breath, heart failure, or angina occur. In the majority of elderly patients, the aortic valve is trileaflet…

Techniques of transseptal puncture

Transseptal catherization was first described by Ross, Braunwald, and Morrow in 1959 as a feasible method to obtain direct left atrial (LA) pressure measurements. Although the use of transseptal puncture (TSP) for hemodynamic assessment had since declined due to the wider application of right heart catheterization, TSP is currently considered an essential component of many valvular and nonvalvular structural heart disease (SHD) interventions ( Fig. 5.1…

Hemodynamics for the structural interventionalist

Introduction Invasive hemodynamic assessment is a critical part of structural intervention. Imaging and hemodynamics are complementary, and both need to be mastered for effectiveness in structural heart disease (SHD) interventions. Indications for diagnostic invasive assessment include: 1. The diagnosis remains ambiguous after noninvasive testing. 2. There is discrepancy in the reported severity of valvular heart disease by different noninvasive measures. 3. There is suspicion for pulmonary…

Imaging for SHD interventions

Introduction The field of transcatheter structural heart interventions has grown tremendously in recent years. Because operators are not able to directly visualize the cardiac anatomy during percutaneous procedures, live imaging is a critical component of safely and successfully performing these procedures. Interventional echocardiography has thus evolved in tandem with the growth of structural heart procedures. Echocardiography has become an important part of preprocedural planning, procedural guidance,…

Access and pitfalls

Introduction Procedural and clinical outcomes for patients referred to the cardiac catheterization laboratory, including those undergoing percutaneous structural heart interventions, depend on obtaining safe and adequate vascular access. Structural heart interventions often require percutaneous vascular access with large-bore sheaths—for example, femoral venous access for transcatheter mitral valve repair (e.g., MitraClip, Abbott Vascular, 24F) or femoral arterial access for transcatheter aortic valve replacement (TAVR, 14–18F). Although transvenous…

Building blocks of structural intervention: An approach for procedural training

Structural heart disease (SHD) intervention is the fastest-growing area in cardiology and cardiac surgery. The number of transcatheter procedures has increased from approximately 5000 procedures in 2012 to over 60,000 cases in 2018 in the United States alone ( Fig. 1.1 ). These numbers are set to increase even further as the market expands into lower-risk patients and procedures become more refined. If TAVR is routinely…